Billings Clinic
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Training Center
2800 Tenth Avenue North
PO Box 37000
Billings, MT 59107-7000 | |
|Name (with credentials if applicable): |
|Mailing Address: |
| |
| |
|Phone: home |
| Work |
|Fax: |
|Email address: |
|AREA OF CERTIFICATION |DEGREE OF CERTIFICATION |DATE OF INITIAL CERTIFICATION |
| | | |
|BLS |( Instructor | |
| | | |
| |TC Faculty | |
| | | |
| |Regional Faculty | |
| | | |
|HEARTSAVER 1ST AID |( Instructor | |
| | | |
|ACLS |( Instructor | |
| | | |
| |TC Faculty | |
| | | |
| |Regional Faculty | |
| | | |
|PALS |( Instructor | |
| | | |
| |TC Faculty | |
| | | |
| |Regional Faculty | |
Please include a copy of both sides of your current instructor and provider cards in each area
for which you are currently certified. (Only for 1st time instructors)
Please return completed registration form to:
Mary Walser
Training Center Assistant Coordinator
Billings Clinic
PO Box 37000
Billings, MT 59107
For Training Center use only
Registration fee: _____Yes______________ CTC instructor # _____________________
Copy of card(s): _____Yes______________ Date enrolled
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